<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Service1')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-service1" class="form-control selectpicker" name="row[service1]">
                {foreach name="service1List" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.service1"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Service2')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-service2" class="form-control selectpicker" name="row[service2]">
                {foreach name="service2List" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.service2"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Service3')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-service3" class="form-control selectpicker" name="row[service3]">
                {foreach name="service3List" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.service3"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Rebate_1')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-rebate_1" class="form-control" name="row[rebate_1]" type="number" value="{$row.rebate_1|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Rebate_2')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-rebate_2" class="form-control" name="row[rebate_2]" type="number" value="{$row.rebate_2|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Rebate_3')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-rebate_3" class="form-control" name="row[rebate_3]" type="number" value="{$row.rebate_3|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Remarks')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-remarks" class="form-control" name="row[remarks]" type="text" value="{$row.remarks|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Status')}:</label>
        <div class="col-xs-12 col-sm-8">
            
            <div class="radio">
            {foreach name="statusList" item="vo"}
            <label for="row[status]-{$key}"><input id="row[status]-{$key}" name="row[status]" type="radio" value="{$key}" {in name="key" value="$row.status"}checked{/in} /> {$vo}</label> 
            {/foreach}
            </div>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>
